Fillable Printable Form 5085 - Bulk Deliveries Of Agricultural Gasoline

Form 5085 - Bulk Deliveries Of Agricultural Gasoline

Missouri Department of Revenue

Bulk Deliveries of Agricultural Gasoline

Form

5085

Company Name

A. Date Delivered

(MM/DD/YYYY)

B. Invoice or Ticket

Number

D. Purchaser’s Address

E. Gallons

Total

__ __ / __ __ / __ __ __ __

Signature of Owner or Authorized Agent Printed Name Title Date (MM/DD/YYYY)

Signature

Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. The gallons listed above were sold as bulk deliveries of agricultural

gasoline in quantities of one hundred gallons or more and delivered to farmers. I further certify that each farmer listed above completed an Agricultural Gasoline Bulk Sales Exemption Certificate,

which is retained in my files. All tickets and invoices indicating the purchaser’s name, date of delivery, and gallons purchased are also retained in my files.

__ __ /__ __ /__ __ __ __

Delivery Information

This schedule(s) provides detail in support of the amount(s) shown as bulk deliveries of agricultural gasoline on Motor Fuel Refund Claim (Form 4923). Submit this form with

Form 4923. Each delivery must be for 100 gallons or more. Each invoice should be listed on a separate line.

__ __ / __ __ / __ __ __ __

C. Name of Purchaser

Form 5085 (Revised 09-2014)

Reset Form

Print Form

Instructions

Company Name is the name for the retailer shown on the motor fuel refund claim.

A. - Date Delivered is the date the product was purchased by the farmer.

B. - Invoice or Ticket Number is the identifying number from the document issued to the farmer when product was delivered.

D. - Purchaser’s Address is the physical location of bulk delivery tank.

E. - Please list the gallons of bulk deliveries of agricultural gasoline purchased by the farmer. Use these figures to complete the Motor Fuel Refund Claim

(Form 4923). Submit this form with Form 4923.

Form 5085 (Revised 09-2014)

Mail To: Taxation Division Phone: (573) 751-7671

P.O. Box 800 Fax: (573) 522-1720

Jefferson City, MO 65105-0800 TTY: (800) 735-2966

E-mail: [email protected]

Visit //www.dor.mo.gov/business/fuel/ for additional information.